Intussusception: Difference between revisions

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==Background==
==Background==
*Most common cause of intestinal obstruction in 6mo-6yr
[[File:Intussusception EN.png|thumb|Schematic of intussusception.]]
**Usually occurs in 6-36 months
*Most common cause of intestinal obstruction in 6 months to 6 years
*Due to telescoping of one part of intestine into another
**Peak incidence at 6-36 months
**Mesentery involvement > ischemia, bloody/mucous stool
*Telescoping of proximal bowel segment (intussusceptum) into distal segment (intussuscipiens)
*Peds
**Ileocolic type is most common in children
**Typically no pathological lesions
**Mesenteric involvement leads to venous congestion → ischemia → bloody/mucous stool
***If > 6 years old, more likely to have a lead point
 
****Lead points: Meckel diverticulum, duplication cyst, polyp, tumor, hematoma, vascular malformation, parasite (eg Ascaris), Henoch-Schonlein purpura
===Pediatrics===
**Slight male predominance - 3:2
*Typically no pathologic lead point (idiopathic in ~90% of cases <3 years)
*Adults
*If > 6 years old, more likely to have a lead point:
**Rare
**Meckel diverticulum, duplication cyst, polyp, lymphoma, [[Henoch-Schonlein purpura]] (HSP) hematoma, Peyer patch hypertrophy
**80% involve small bowel
*Often preceded by viral URI or [[gastroenteritis]] (lymphoid hyperplasia)
**70% risk of malignancy
*Slight male predominance (3:2)
*Rotavirus vaccine associated with slightly increased risk in first week after dose
 
===Adults===
*Rare; accounts for 1-5% of bowel obstruction in adults
*80% involve small bowel
*70% associated with pathologic lead point (malignancy in up to 50% of colonic cases)


==Clinical Features==
==Clinical Features==
*Classic Triad:
===Pediatrics===
**Sudden colicky pain
*Intermittent, colicky abdominal pain with episodes every 15-20 minutes
**Palpable sausage shaped mass on right
**Child draws knees to chest during episodes
**Currant jelly stool (only 50% of cases; late manifestation of the disease)
**Asymptomatic intervals between episodes (child may appear well and playful)
*Intermittent episodes of pain
*[[Vomiting]] (initially non-bilious; bilious in late stages)
**Child pulls up knees
*Lethargy may be sole presentation ("neurologic intussusception")
**May be asymptomatic between episodes
**May present with isolated seizure and abdominal pain<ref>Kleizen KJ et al. Acta Paediatr. 2009;98(11):1822-4. PMID 19664012</ref>
***May be completely benign, smiling, playful
*Classic triad present in only ~21% of cases<ref>Bruce J, et al. Intussusception: evolution of current management. ''J Pediatr Gastroenterol Nutr''. 1987;6:663-674. PMID 3430268</ref>:
**Suspect if recurrent brief pain episodes, especially if wake child from sleep
**Sudden colicky abdominal pain
**Later stages may be associated with lethargy
**Palpable sausage-shaped mass (right upper quadrant/epigastric)
*May have vomiting (non-bilious, late stages bilious)
**Currant jelly stool (only ~50%; late finding indicating mucosal ischemia)
*May present as lethargy alone, without any of the classic triad
*Dance sign: emptiness in RLQ (cecum displaced superiorly)
*Late: peritonitis, [[shock]], [[sepsis]]
 
===Adults===
===Adults===
*Typically have partial/SBO symptoms
*Typically partial/[[small bowel obstruction]] symptoms
*Vomiting, rectal bleeding, constipation
*Vomiting, abdominal distension, constipation, rectal bleeding
*Distended
*Late: [[sepsis]], perforation
*Late Stage: sepsis


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
*Classic Triad not always present
*Classic triad not always present — maintain high index of suspicion
**Maintain high index of suspicion
*Labs are nonspecific; obtain if concerned for complications:
*All labs nonspecific
**CBC, BMP, lactate (if concern for bowel ischemia)
*Guaiac-positive stool (~50%)
**Guaiac-positive stool (~50%)


===Imaging===
===Imaging===
*[[Ultrasound: Abdomen|Ultrasound]]
====Ultrasound (Test of Choice in Pediatrics)====
**Sensitivity and specificity approach 100%, but operator dependent
[[File:Ultrasound intussusception.jpg|thumb|Ultrasound showing characteristic target sign for intussusception.]]
***Some emergency departments have successfully implemented bedside point-of-care ultrasound
[[File:Intussusception long and short axis.jpg|thumb|Intussusception in both short axis and longitudinal view<ref>http://www.thepocusatlas.com/pediatrics/</ref>]]
**Classically see bulls eye lesion
*Sensitivity and specificity approach 100% (operator dependent)
**Ultrasound can diagnose ileo-ileal intussusception, whereas contrast enema cannot
*Target/doughnut sign (short axis): concentric rings of bowel wall
**Negative ultrasound = may still be intermittent intussusception
*Pseudokidney sign (long axis): layered appearance
*Air contrast enema
*Can identify ileo-ileal intussusception (contrast enema cannot)
**Diagnostic and frequently curative
*Successfully implemented as bedside POCUS in many EDs
**Prior to procedure, IV hydration, NG tube decompression, surgery consult
**Technique: linear probe, graded compression over all 4 abdominal quadrants
*Hydrostatic (saline or water-soluble contrast) enema also may be used
*Negative US does not completely exclude intermittent intussusception
*CT for adults (air contrast or barium enemas not sufficient)<ref>Marinis A et al. Intussusception of the bowel in adults: A review. World J Gastroenterol. 2009 Jan 28; 15(4): 407–411.</ref>
 
**Up to 20% of cases do not have lead point
====Other Imaging====
*Air-contrast enema: both diagnostic and therapeutic (see Management)
*CT abdomen: preferred in adults<ref>Marinis A et al. Intussusception of the bowel in adults: A review. ''World J Gastroenterol''. 2009;15(4):407-411. PMID 19152443</ref>
**Target sign, sausage-shaped mass, lead point identification
**Up to 20% of adult cases lack identifiable lead point


==Management==
==Management==
*Stable children with a high clinical suspicion and/or radiographic evidence of intussusception and no evidence of bowel perforation should be treated with nonoperative reduction
===Pediatric===
**NPO
*NPO and IV access
**Consider NG tube as indicated
*IV fluid resuscitation prior to reduction
**Air-contrast enema (reduces 80%)
*NG tube if bilious vomiting or significant distension
**Hydrostatic (saline or water-soluble contrast) may also be used
*Surgery consult prior to attempted reduction
*Surgery consult
 
**Surgery is indicated when nonoperative reduction is incomplete, or patient is toxic, or has perforation or peritonitis.
====Nonoperative Reduction (First-line for Stable Patients)====
**In stable, asymptomatic patient with ileo-ileal intussusception, short length of intussusception <2.3 cm, expectant management is reasonable as many of these cases will resolve spontaneously
*Indicated if no evidence of perforation, peritonitis, or hemodynamic instability
**In all adults with intussusception due to high incidence of malignancy
*Air-contrast enema (preferred at most centers):
**Success rate: 80-95%
**Performed by radiology with surgery on standby
**Contraindicated if perforation, peritonitis, or shock
*'''Hydrostatic enema''' (saline or water-soluble contrast): alternative method
*Rule of 3s: maximum 3 attempts of reduction, each lasting 3 minutes, with 3 minutes rest between
 
====Surgical====
*Indicated when:
**Nonoperative reduction incomplete or unsuccessful
**Patient is hemodynamically unstable, toxic, or has perforation/peritonitis
**Pathologic lead point identified
**Recurrent intussusception (relative indication)
 
====Special Situations====
*Ileo-ileal intussusception (small bowel only, often incidental):
**If stable, asymptomatic, and length <2.3 cm → expectant management reasonable (many resolve spontaneously)
*Post-reduction observation: monitor for recurrence and complications for minimum 12-24 hours
 
===Adults===
*Surgical management is standard due to high incidence of malignancy
*CT for preoperative planning and lead point identification


==Disposition==
==Disposition==
*Admit
*Admit after successful reduction for observation (minimum 12-24 hours)
*Recurrence occurs in ~10% of cases reduced by enema
*Consider discharge only if:
**initial management same
**Successful reduction confirmed
**Good follow-up available
**Reliable parents with understanding of recurrence signs
**Reasonable distance to hospital
*Recurrence rate: 5-12%<ref>Gray MP, et al. Recurrence rates after intussusception enema reduction: a meta-analysis. ''Pediatrics''. 2014;134(1):110-9. PMID 24935999</ref><ref>Beres AL, et al. Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission. ''J Pediatr Surg''. 2014;49(5):750-2. PMID 24851761</ref>
**Majority of recurrences do NOT occur within first 24-48 hours


==See Also==
==See Also==
*[[Abdominal Pain (Peds)]]
*[[Abdominal pain (peds)]]
*[[Small bowel obstruction]]
*[[Volvulus]]
*[[Henoch-Schonlein purpura]]
*[[Ultrasound: Abdomen]]
*[[Ultrasound: Abdomen]]


==References==
==References==
<references/>
<references/>
*Waseem M, Rosenberg HK. Intussusception. ''Pediatr Emerg Care''. 2008;24(11):793-800. PMID 19018227
*Gluckman S, et al. Management for intussusception in children. ''Cochrane Database Syst Rev''. 2017;6:CD006476. PMID 28617038


[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:GI]]
[[Category:GI]]

Latest revision as of 09:29, 22 March 2026

Background

Schematic of intussusception.
  • Most common cause of intestinal obstruction in 6 months to 6 years
    • Peak incidence at 6-36 months
  • Telescoping of proximal bowel segment (intussusceptum) into distal segment (intussuscipiens)
    • Ileocolic type is most common in children
    • Mesenteric involvement leads to venous congestion → ischemia → bloody/mucous stool

Pediatrics

  • Typically no pathologic lead point (idiopathic in ~90% of cases <3 years)
  • If > 6 years old, more likely to have a lead point:
    • Meckel diverticulum, duplication cyst, polyp, lymphoma, Henoch-Schonlein purpura (HSP) hematoma, Peyer patch hypertrophy
  • Often preceded by viral URI or gastroenteritis (lymphoid hyperplasia)
  • Slight male predominance (3:2)
  • Rotavirus vaccine associated with slightly increased risk in first week after dose

Adults

  • Rare; accounts for 1-5% of bowel obstruction in adults
  • 80% involve small bowel
  • 70% associated with pathologic lead point (malignancy in up to 50% of colonic cases)

Clinical Features

Pediatrics

  • Intermittent, colicky abdominal pain with episodes every 15-20 minutes
    • Child draws knees to chest during episodes
    • Asymptomatic intervals between episodes (child may appear well and playful)
  • Vomiting (initially non-bilious; bilious in late stages)
  • Lethargy may be sole presentation ("neurologic intussusception")
    • May present with isolated seizure and abdominal pain[1]
  • Classic triad present in only ~21% of cases[2]:
    • Sudden colicky abdominal pain
    • Palpable sausage-shaped mass (right upper quadrant/epigastric)
    • Currant jelly stool (only ~50%; late finding indicating mucosal ischemia)
  • Dance sign: emptiness in RLQ (cecum displaced superiorly)
  • Late: peritonitis, shock, sepsis

Adults

Differential Diagnosis

Pediatric Abdominal Pain

0–3 Months Old

3 mo–3 y old

3 y old–adolescence

Evaluation

  • Classic triad not always present — maintain high index of suspicion
  • Labs are nonspecific; obtain if concerned for complications:
    • CBC, BMP, lactate (if concern for bowel ischemia)
    • Guaiac-positive stool (~50%)

Imaging

Ultrasound (Test of Choice in Pediatrics)

File:Ultrasound intussusception.jpg
Ultrasound showing characteristic target sign for intussusception.
File:Intussusception long and short axis.jpg
Intussusception in both short axis and longitudinal view[3]
  • Sensitivity and specificity approach 100% (operator dependent)
  • Target/doughnut sign (short axis): concentric rings of bowel wall
  • Pseudokidney sign (long axis): layered appearance
  • Can identify ileo-ileal intussusception (contrast enema cannot)
  • Successfully implemented as bedside POCUS in many EDs
    • Technique: linear probe, graded compression over all 4 abdominal quadrants
  • Negative US does not completely exclude intermittent intussusception

Other Imaging

  • Air-contrast enema: both diagnostic and therapeutic (see Management)
  • CT abdomen: preferred in adults[4]
    • Target sign, sausage-shaped mass, lead point identification
    • Up to 20% of adult cases lack identifiable lead point

Management

Pediatric

  • NPO and IV access
  • IV fluid resuscitation prior to reduction
  • NG tube if bilious vomiting or significant distension
  • Surgery consult prior to attempted reduction

Nonoperative Reduction (First-line for Stable Patients)

  • Indicated if no evidence of perforation, peritonitis, or hemodynamic instability
  • Air-contrast enema (preferred at most centers):
    • Success rate: 80-95%
    • Performed by radiology with surgery on standby
    • Contraindicated if perforation, peritonitis, or shock
  • Hydrostatic enema (saline or water-soluble contrast): alternative method
  • Rule of 3s: maximum 3 attempts of reduction, each lasting 3 minutes, with 3 minutes rest between

Surgical

  • Indicated when:
    • Nonoperative reduction incomplete or unsuccessful
    • Patient is hemodynamically unstable, toxic, or has perforation/peritonitis
    • Pathologic lead point identified
    • Recurrent intussusception (relative indication)

Special Situations

  • Ileo-ileal intussusception (small bowel only, often incidental):
    • If stable, asymptomatic, and length <2.3 cm → expectant management reasonable (many resolve spontaneously)
  • Post-reduction observation: monitor for recurrence and complications for minimum 12-24 hours

Adults

  • Surgical management is standard due to high incidence of malignancy
  • CT for preoperative planning and lead point identification

Disposition

  • Admit after successful reduction for observation (minimum 12-24 hours)
  • Consider discharge only if:
    • Successful reduction confirmed
    • Good follow-up available
    • Reliable parents with understanding of recurrence signs
    • Reasonable distance to hospital
  • Recurrence rate: 5-12%[5][6]
    • Majority of recurrences do NOT occur within first 24-48 hours

See Also

References

  1. ↑ Kleizen KJ et al. Acta Paediatr. 2009;98(11):1822-4. PMID 19664012
  2. ↑ Bruce J, et al. Intussusception: evolution of current management. J Pediatr Gastroenterol Nutr. 1987;6:663-674. PMID 3430268
  3. ↑ http://www.thepocusatlas.com/pediatrics/
  4. ↑ Marinis A et al. Intussusception of the bowel in adults: A review. World J Gastroenterol. 2009;15(4):407-411. PMID 19152443
  5. ↑ Gray MP, et al. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014;134(1):110-9. PMID 24935999
  6. ↑ Beres AL, et al. Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission. J Pediatr Surg. 2014;49(5):750-2. PMID 24851761
  • Waseem M, Rosenberg HK. Intussusception. Pediatr Emerg Care. 2008;24(11):793-800. PMID 19018227
  • Gluckman S, et al. Management for intussusception in children. Cochrane Database Syst Rev. 2017;6:CD006476. PMID 28617038
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